Prevention Working Copy · •There is some evidence that those with Vascular Dementia survive...

Rational Preventive Care in theContext of DementiaAMY THOMAS , MD, RESEARCH FEL LOW,VA PUGET SOUND HEALTH CARE SYSTEM

Disclosures• No financial disclosures

Prevention Care in Dementia (Thomas), NW GWEC Spring 2020 1

Objectives

• Describe the prognoses of different types of Dementia.

• Identify the horizon to benefit of common prevention plans.

• Discuss the advantages of patient centered approaches to the care ofindividuals with Dementia.

Case74 y/o gentleman with history of HTN, HLD, BPH, COPD and recent diagnosis of probable Alzheimer’sDementia (MOCA 18/30) presents to initiate care in your Geriatrics clinic.

•He has lived with his wife in a 2 story home for 30 years.

•He is independent in his ADLs but for the last year has required assistance with finances and has limitedhimself to “non highway” driving. He has had a couple falls this year and “furniture surfs” but won’t useany assistive devices.

•He has a history of smoking but stopped approximately 10 years ago.

•He has no currently documented Advanced Directives or Goals of Care

•His wife notes he is due for his colonoscopy and annual prostate specific antigen (PSA) test.


Concept: Prognosis•Forecast of the likely course of a disease

•A few good tools to look at prognosis for patients in general (not Dementia specific):https://www.myabaris.com/tools/life expectancy calculator how long will i live/https://eprognosis.ucsf.edu/

Concept: Prognosis


Case Patient Prognosis

Concept: Prognosis 1 year


One yearmortalityfor our case

Concept: Prognosis Over Time


Concept: Prognosis Over Time

5, 10 and 14 year mortality rates for ourpatient


Prognosis by Dementia Sub type•Complex and influenced by age, co morbidities, dementia severity at the time of diagnosis and manyconfounders (race, socioeconomic status, etc.).

•5 8 years on average from time of diagnosis to death, for late onset (after age 65) Dementia.

•There is some evidence that those with Vascular Dementia survive for a shorter time (likely due to risk ofdeath by cardiovascular disease).

HTTPS://WWW.ALZ.ORG/MEDIA/DOCUMENTS/ALZHEIMERS FACTS AND FIGURES.PDF, HTTPS://WWW.ALZHEIMERS.ORG.UK/,HTTPS://WWW.NINDS.NIH.GOV/

Prognosis byDementiaSub type•A recent large (n~15,000)Swedish cohort study adjustedfor age, gender, MMSE score,residential setting and numberof medications at time ofdementia work up. Comparingsurvival time (days) they foundFrontotemporal Dementia (FTD)had a faster rate of death thenthe other dementia sub types.

GARCIA PTACEK S, FARAHMAND B, KAREHOLT I, RELIGA D, CUADRADO ML, ERIKSDOTTER M (2014) MORTALITY RISK AFTER DEMENTIA DIAGNOSIS BY DEMENTIA TYPE AND UNDERLYINGFACTORS: A COHORT OF 15,209 PATIENTS BASED ON THE SWEDISH DEMENTIA REGISTRY. J ALZHEIMERS DIS 41:467–477


Concept: Horizon To Benefit

•Length of time needed to gain a clinically meaningful risk reduction for a specificoutcome.• Examples:

• SSRI and “weeks” for depression• Anti platelet medication and “same day” for acute myocardial infarction.

GUIDING PRINCIPLES FOR THE CARE OF OLDER ADULTS WITH MULTIMORBIDITY: AN APPROACH FOR CLINICIANS. GUIDING PRINCIPLES FOR THE CARE OF OLDER ADULTS WITH MULTIMORBIDITY: AN APPROACHFOR CLINICIANS: AMERICAN GERIATRICS SOCIETY EXPERT PANEL ON THE CARE OF OLDER ADULTS WITH MULTIMORBIDITY. J AM GERIATR SOC. 2012;60(10):E1–E25. DOI:10.1111/J.1532 5415.2012.04188.X

Concept:PatientCenteredCare

HTTP://WWW.IHI.ORG/ENGAGE/INITIATIVES/AGE FRIENDLY HEALTH SYSTEMS/DOCUMENTS/IHIAGEFRIENDLYHEALTHSYSTEMS_GUIDETOUSING4MSCARE.PDF


Concept: PreventionPrimary Prevention: Goal is to prevent getting a disease (e.g.:vaccination)

Secondary Prevention: Goal is to detect a disease early toprevent it from getting worse (e.g.: breast cancer screening)

Tertiary Prevention: Goal is to improve quality of life and/orreduce the symptoms of diseases you already have. (e.g.:Cardiac Rehabilitation Program)

Caveats• Recommendations consider

guidelines for older adults(eg: US Preventive Task Force,American Cancer Society)

• Individuals with Dementia areoften excluded from researchthat supports theseguidelines.

• Recommendations ultimatelyrely on expert opinion andpersonal clinical experience


PrimaryPrevention

Goal is to prevent gettinga disease

Vaccinations CDC RecommendationsTd: Once every 10 years.

Pneumonia 23 valent: All adults >65 years.

Pneumonia 13 valent: Recommended for adults with a condition that weakens the immune system, CSFleak or cochlear implant. **nursing home residents are at higher risk then general population.

Influenza: Yearly

Shingles: Healthy adults >50 years.


Exercise•Unclear if exercise lowers the risk of getting Dementia or slows its progression

•Exercise can help with mood and other comorbidities (HTN, heart disease)

•Moderate to Severe Dementia often leads to increased apathy to activities the person with dementia usedto enjoy

•Exercise can help maintain functionality (possibly minimizing future caregiver burden).

• Persons with Dementia are more likely to gain from PT referrals if a caregiver can attend with them.

Diet•No known dietary cure to decrease risk of Dementia or limit progression of Dementia.

•A healthy diet is important to decrease the risk of other chronic diseases that may impact the risk ofDementia (esp. Vascular sub type).

•Dementia may impact appetite, swallow and cravings

•Feeding tubes are not recommended to either minimize aspiration or extended life.


SecondaryPrevention

Goal is to detect adisease early toprevent it fromgetting worse

Breast Cancer•USPSTF (2016) recommends screening via mammogram of allwomen ages 50 74 biennially. No evidence exists for women >75.

•ACS (2015) recommends annual screening from 45 to 54 withopportunity to transition to biennial screening at 55. Continue ifhealth is good and life expectancy of 10 years or longer.

•Breast self exam and clinical screening exams are no longerrecommended.


Prostate Cancer

•USPSTF (2018): Ages 55 69 shared decision making. >70, do not screen.

•ACS (2010): Men 50 and older with at least 10 year life expectancyshould discuss pros and cons of screening with doctor and makeinformed decision.

Colon Cancer•USPSTF (2016) recommends screening from ages 50 to 75 for colon cancer with shared decision making forages 76 84 and recommendation against screening if >85.• Screening most often includes either lab test (FOBT or FIT) yearly or colonoscopy at least every 10 years (morefrequently depending on risk factors)

•ACS (2018) recommends people who are in good health and with a life expectancy of more than 10 yearsshould continue regular colorectal cancer screening through age 75. Ages 76 84 decision based onpreferences, life expectancy, overall health and prior screening history. Over 85 should no longer getcolorectal cancer screening.

HTTPS://WWW.DEMENTIA.ORG.AU/FILES/HELPSHEETS/HELPSHEET DEMENTIAQANDA20 ANAETHESIA_ENGLISH.PDF


Lung Cancer•USPSTF (2014) recommends annual screening for patients ages 55 80 with at least a 30 pack year history ofsmoking who are currently smoking or who have quit within the last 15 years• Data based on study that enrolled adults up to age 74 (only 10% of sample >70 y/o).• Original study excluded those who were unlikely to complete a curative lung cancer surgery or those with conditionsthat gave them a substantial risk of death in the next 8 years.

• “Screening may not be appropriate for patients with substantial comorbid conditions, particularly those at theupper end of the screening range”

•ACS recommends screening in ages 55 74 and good health (Same smoking history as above).

Cervical Cancer•USPTF (2018): Screening can stop once a woman reaches65 IF she has a history of 3 negative tests in a row OR ahistory of hysterectomy including the cervix AND nohistory of abnormal PAP (CIN II or greater). Oncescreening has stopped it should not start again even ifpatient reports a new sexual partner.


Cancer Screening in Dementia Summary•Given an average prognosis of 4 8 years for patients with all kind ofDementia and horizon to benefit estimated at 10 years, cancerscreening should be discouraged.

•Patients with Dementia are at heightened risk of deliriumassociated with anesthetic and should be particularly beencouraged to consider this risk when weighing the risks andbenefits of colon cancer screening with direct visualization.

Osteoporosis•USPSTF (2018): recommends screening for osteoporosis in women65 years and older. Insufficient evidence for men.

•Endocrine Society (2012): We recommend testing higher risk men(aged>=70 or aged 50 69 who have risk factors (e.g. low bodyweight, prior fracture as an adult, smoking, etc.).

•Horizon to Benefit of osteoporosis treatment to limit risk of futurefracture estimated in the 2 5 year range.

•If treating, consider IV bisphosphonates• Memory concerns with once weekly therapy and need to remain uprightafter oral administration.

BERRY SD, SHI S, KIEL DP. CONSIDERING THE RISKS AND BENEFITS OF OSTEOPOROSIS TREATMENT IN OLDER ADULTS. JAMA INTERNMED.2019;179(8):1103–1104. DOI:10.1001/JAMAINTERNMED.2019.0688


Abdominal Aortic Aneurysm•USPTF (2019): 1 time screening recommended in men ages 65 75who have ever smoked. Screening is NOT recommended in womenwho have never smoked (insufficient evidence for women with ahistory of smoking).

•Limited evidence of risk/benefit with less invasive endoscopicapproaches, however, do not currently recommend screening forthose with Dementia.

Hearing Loss Screen•USPTF (2012) Insufficient evidence to screen for hearing loss inadults ages 50 years and older.

•Hearing loss is a risk factor for a Dementia• Impact attention/memory• Impact test performance

•Pocket talker vs. Hearing Aids


Vision Screen•USPTF (2016): Insufficient evidence to assess the balance of benefits and harms of screening for impairedvisual acuity or open angle glaucoma (2013) in older adults.

•CDC STEADI campaign recommends vision screen for older adults at high risk of falls

Hypertension•American Heart Association/JNC 8 (2014): goal BP in patients >60 should be <150/90.

• If history of Diabetes goal <140/90 regardless of age

•SPRINT Senior Trial (2016):• Sub analysis of patients >75 y/o in SPRINT trial. Showed better cardiovascular outcomes in patients with goal of SBP<120 as compared with <140. (similar rates of falls and orthostatic hypotension in both arms). **of note patientswith Dementia were excluded from this study

•Avoid overtreatment in patients with Dementia• Home vs. In Office BP values (white coat hypertension!)• Falls, Hyponatremia, AKI risks (re consider diuretics in particular)• Watch for changing dose needs with weight loss!


Diabetes Management•American Geriatrics Society: Goal A1c 7.5 8% in older patients with moderate comorbidities and a lifeexpectancy of less than 10 years.

•American Diabetes Association recommends 8 8.5% A1c goal for older patients with complex medicalissues.

•ACCORD/ADVANCE trial secondary analysis showed increased risk of cardiovascular events in patients withhigh risk of hypoglycemia (likely 2/2 catecholamine surges).

•Dementia is a major risk factor for hypoglycemia.

How to Talk about Limiting SecondaryPrevention Efforts

•“offering a discussion of life expectancy to patients whileprefacing that patients can decline was acceptable to mostolder adults”

•“helpful to discuss what alternative health issues would beprioritized, such as addressing active symptoms patientsmay have, instead of cancer screening so as to not feel likethey were receiving less care”

NANCY L SCHOENBORN, MD, MHS, CYNTHIA M BOYD, MD, MPH, SEI J LEE, MD, MAS, DANELLE CAYEA, MD, MS, CRAIG E POLLACK, MD, MHS, COMMUNICATING ABOUT STOPPING CANCER SCREENING: COMPARINGCLINICIANS’ AND OLDER ADULTS’ PERSPECTIVES, THE GERONTOLOGIST, VOLUME 59, ISSUE SUPPLEMENT_1, JUNE 2019, PAGES S67–S76, HTTPS://DOI.ORG/10.1093/GERONT/GNY172


TertiaryPrevention

Goal is to improvequality of life and/orreduce the symptomsof diseases youalready have.

AnticipatoryGuidance: Goals ofCare

•Discussing a patient’s goals for theircare is essential in early Dementia toensure the patient’s preferences areheard.

•A Dementia specific AdvancedDirective is available:https://dementia directive.org/

•More on this topic in May 2020 talk byDr. Carpenter!


Anticipatory Guidance: Durable Power ofAttorney for Healthcare and Finances

•Early Dementia is also an important time to designate and complete legal paperwork for power of attorneyfor health care and finances.

•The power of attorney will only speak for the patient when the patient does not have capacity to speak forthemselves.• Patient capacity is not fixed and can vary depending on the time of day or complexity of the question.

•Consider seeking the advice of an elder law attorney: https://www.naela.org/findlawyer

Anticipatory Guidance: Driving•At time of Dementia diagnosis starting planning for when to limit and stop driving (including making plansfor alternative transportation)• Risks include accidents, getting lost, driving too slowly, harm of others/legal liability

•OT and/or Neuro Psychiatry testing can help weigh in on patient driving safety. Department of Licensingalso does safe driving exams.

HTTPS://S0.HFDSTATIC.COM/SITES/THE_HARTFORD/FILES/CMME CROSSROADS.PDF


Anticipatory Guidance: DrivingResource Hartford Center

“The guide provides suggestions for monitoring, limitingand stopping driving. The information incorporates theexperiences of family caregivers and people withdementia, as well as suggestions from experts inmedicine, gerontology and transportation.”

AnticipatoryGuidance: DrivingResource Alzheimer’sAssociation

•“For people in the early stages ofAlzheimer's, it is never too soonto plan ahead for how you willget around when you can nolonger drive. Putting a plan inplace can be an empowering wayto make your voice heard.”

HTTPS://WWW.ALZ.ORG/HELP SUPPORT/CAREGIVING/SAFETY/DEMENTIA DRIVING


AnticipatoryGuidance: GunSafety

For patients in the early stagesof dementia, Sussman says shemight tell them, " 'You're goingto need to retire from drivingand retire from the use offirearms.' Which changes itfrom, 'We need to take theseaway' or 'You need to stop.' Solet's plan."

AnticipatoryGuidance: HomeSafety Evaluation

• Excellent checklist for home safety assessment at:https://www.alz.org/help support/caregiving/safety/home safety

• Also consider formal Home Health Occupational Therapy referral.• Assist with door disguise or alternative lock systems to minimize

wandering• Address tripping hazards to limit falls• Assess the need for assistive devices to make bathing and

ambulating safer.

• Cooking/Hot Water and Risks of Burns


Anticipatory Guidance: AvoidingHospitalization

•Dementia is associated with 2x the risk of Hospitalization as similarly agedadults.

•Hospitalization of patients with Dementia can be Harmful:• Increased risk of Delirium• Functional loss from limited mobilization• Iatrogenic errors/harm

• Treating Dementia Associated Behaviors• Not recognizing changes from patient’s baseline• Attributing symptoms inappropriately to Dementia

PHELAN EA, BORSON S, GROTHAUS L, BALCH S, LARSON EB. ASSOCIATION OF INCIDENT DEMENTIA WITH HOSPITALIZATIONS. JAMA. 2012;307(2):165–172.DOI:10.1001/JAMA.2011.1964

Anticipatory Guidance:Caregiver Burnout

•Caregivers of patient’s with Dementia are at higher risk of burnout thencaregivers to patients with other medical conditions.• 2/3 are women and approximately 1/3 are >65.• 30 40% report having depression• Many resources exist to help!

•A small sampling of resources:• Alzheimer’s Association• Area Agency on Aging (Adult Day Health Program, Respite Links,Caregiver Support Groups)

• Memory Brain Wellness Clinic UW


In Review:•Dementia is a terminal illness and on average the prognosis from diagnosis to death is 4 8 years.

•If the horizon to benefit of a preventive therapy is longer than 4 8 years, it is unlikely to benefit patientswith Dementia (including cancer screening).

•Some preventive care has an appropriate Horizon to Benefit (e.g. screening/treatment for osteoporosis andproviding anticipatory guidance about plans to enhance safety and quality of life living with Dementia).

•Patient centered care will ensure that the goals of the person with Dementia and their family remain frontand center for all medical decision making.

Questions?


Date post:	30-Jun-2020
Category:	Documents
Upload:	others
View:	0 times
Download:	0 times

Prevention Working Copy · •There is some evidence that those with Vascular Dementia survive...

Documents